Pneumococcal Vaccine for Adults Aged ≥19 Years: Recommendations of the Advisory Committee on Immunization Practices, United States, 2023
Authors: Miwako Kobayashi, Tamara Pilishvili, Jennifer L. Farrar, Andrew J. Leidner, Ryan Gierke, Namrata Prasad, Pedro Moro, Doug Campos-Outcalt, Rebecca L. Morgan, Sarah S. Long, Katherine A. Poehling, Adam L. Cohen
Journal: MMWR Recommendations and Reports (2023)

This report compiles and summarizes all published recommendations from CDC's Advisory Committee on Immunization Practices (ACIP) for use of pneumococcal vaccines in adults aged ≥19 years in the United States.This report also includes updated and new clinical guidance for implementation from CDC.Before 2021, ACIP recommended 23-valent pneumococcal polysaccharide vaccine (PPSV23) alone (up to 2 doses), or both a single dose of 13-valent pneumococcal conjugate vaccine (PCV13) in combination with 1-3 doses of PPSV23 in series (PCV13 followed by PPSV23), for use in U.S. adults depending on age and underlying risk for pneumococcal disease.In 2021, two new pneumococcal conjugate vaccines (PCVs), a , were licensed for use in U.S. adults aged ≥18 years by the Food and Drug Administration.ACIP recommendations specify the use of either PCV20 alone or PCV15 in series with PPSV23 for all adults aged ≥65 years and for adults aged 19-64 years with certain underlying medical conditions or other risk factors who have not received a PCV or whose vaccination history is unknown.In addition, ACIP recommends use of either a single dose of PCV20 or ≥1 dose of PPSV23 for adults who have started their pneumococcal vaccine series with PCV13 but have not received all recommended PPSV23 doses.Shared clinical decision-making is recommended regarding use of a supplemental PCV20 dose for adults aged ≥65 years who have completed their recommended vaccine series with both PCV13 and PPSV23.Updated and new clinical guidance for implementation from CDC includes the recommendation for use of PCV15 or PCV20 for adults who have received PPSV23 but have not received any PCV dose.The report also includes clinical guidance for adults who have received 7-valent PCV (PCV7) only and adults who are hematopoietic stem cell transplant recipients.US Department of Health and Human Services/Centers for Disease Control and Prevention leak, or a cochlear implant (11).In 2014, ACIP recommended routine use of PCV13 in series with PPSV23 for all adults aged ≥65 years (12).This recommendation was supported by a large, randomized controlled trial (RCT) among pneumococcal vaccine-naïve, community-dwelling adults aged ≥65 years in the Netherlands that demonstrated efficacy of PCV13 against noninvasive pneumococcal pneumonia (13).In June 2019 ACIP voted to no longer routinely recommend PCV13 for all adults aged ≥65 years and, instead, to recommend PCV13 on the basis of shared clinical decision-making for adults aged ≥65 years who do not have an immunocompromising condition, a CSF leak, or a cochlear implant ( 14).The rationale for this decision was based on additional years of data that found minimal changes in the incidence of pneumococcal disease preventable by PCV13 among adults after the PCV13 recommendation for all adults aged ≥65 years was implemented and on the historically low levels of PCV13-type disease attributed to the indirect effects of pediatric PCV13 use.Although anatomic or functional asplenia, chronic renal failure, and nephrotic syndrome might not be considered immunocompromising ( 15), these conditions are included under immunocompromising conditions for pneumococcal vaccine recommendations because of the similarities in the vaccine recommendations.* Serotypes 15B and 15C are identified together as 15B/15C in the SSUAD test used in this study.$217,000 $93,000-$182,000 ¶ ¶ Abbreviations: IPD = invasive pneumococcal disease; NBPP = nonbacteremic pneumococcal pneumonia; PCV = pneumococcal conjugate vaccine; PCV13 = 13-valent pneumococcal conjugate vaccine; PCV15 = 15-valent pneumococcal conjugate vaccine; PCV20 = 20-valent pneumococcal conjugate vaccine; PPSV23 = 23-valent pneumococcal polysaccharide vaccine; QALY = quality-adjusted life-year; USD = U.S. dollars; VE = vaccine effectiveness.* In any scenario, the Tulane-CDC and Merck models start with a single-aged cohort of individuals, not a full population composed of many different ages.For this reason, these models have one specific starting age.For example, a cohort aged 70 years might be used to represent and estimate values in the group aged ≥65 years.† The Pfizer model base case used a multicohort model; however, single cohort results were provided in a scenario.§ The Tulane-CDC model includes one societal perspective component (i.e., travel cost added to the cost of vaccine administration).The Merck model provided a scenario using the societal perspective that was similar to the Tulane-CDC model.¶ The Tulane-CDC and Pfizer models included scenarios where no herd effects from pediatric vaccinations occurred.** The Tulane-CDC model varied PPSV23 VE against NBPP across two risk groups (adults with or without immunocompromising conditions).The Merck model varied PPSV23 VE against NBPP across three risk groups (low risk, at risk, and high risk).† † The Tulane-CDC and Merck models varied inpatient NBPP case-fatality ratios by age.The Pfizer model varied inpatient NBPP case-fatality ratios by age and risk group.§ § Original report was in 2021 USD, multiplied by 1.10 to adjust to 2022 USD.¶ ¶ The Merck model did not report a value for the comparison.The incremental value was calculated by the CDC team.*** Original report was in 2020 USD, multiplied by 1.15 to adjust to 2022 USD.ranged from $87,000 (Pfizer model: PCV20 administered 7 years after the PCV13 dose) to $611,000 (Tulane-CDC model: PCV20 administered to adults aged 66 years with an immunocompromising condition 1 year after the PCV13 dose).The Merck model did not report a value for this comparison.However, on the basis of calculations by the CDC review team, the Merck model estimated values that would be between the Pfizer and Tulane-CDC model estimates.